Older people at the beginning of the COVID-19 pandemic: A scoping review

This scoping review focuses on evidence gaps regarding the effects on health, social participation and life contexts of older people at the beginning of the COVID-19 pandemic. It is based on a systematic search strategy of the international literature covering a period between December 2019 and June 2020. The review is supplemented by a search of the websites of selected organisations in Germany (cut-off date: 29 June 2020). Search hits were differentiated by types of publication (empirical study, review, discussion paper). The contents were summarised in tabular form according to topic. The publications mainly discussed the high risks of suffering severe courses of COVID-19 faced by older people, specifically those belonging to certain subgroups. In addition, further main topics were the pandemic’s indirect impacts on physical and mental health, physical and cognitive functions and participation in society. Social isolation, loneliness, reduced levels of physical activity and difficulties in maintaining care were discussed as major health risks. Ageism was an issue that was addressed across all of the identified topics. The publications highlighted the need, but also the opportunity, for raising public awareness of the needs of older people in various life contexts. Publications pointed to the urgent need for research into the biological and social causes of older peoples’ high infection risk and how measures could be adapted in a differentiated manner (infection prevention and control measures, social support, medical and nursing care).


Introduction
People aged 60 years and older and, in particular, men aged 80 years and older or with pre-existing medical conditions are considered the main risk groups for a severe or fatal Coronavirus Disease 2019 (COVID-19); men are generally considered to be at greater risk than women [1][2][3][4]. As a vaccine and effective medication to treat COVID-19 were not available when the pandemic broke out, non-pharmaceutical interventions were key to containing the spread of SARS-CoV-2 and preventing the health system from becoming overwhelmed. As early as March 2020, a number of measures to limit physical contact between people were implemented, first in Italy and later across all European countries, including recommendations or regulations instructing those with respiratory symptoms to self-isolate, closure of schools, kindergartens and care facilities, and wide-ranging restrictions on movement and 5 FOCUS Collating, summarising and reporting the results The collated and summarised results were presented in tabular form. The results of the literature search in international databases (Table 1) and the results of the internet search on the websites of selected organisations in Germany were analysed separately ( Table 2). To increase readability and avoid redundancies with the result table, the summary of the results is presented below without references.
Results from the international systematic literature search were sorted based on topic, methodology and main results. In addition, all included publications were categorised according to publication type (discussion paper, review or empirical study) and the publication's country of origin or the first author documented.
Since the scoping review aimed to provide a summary of existing scientific knowledge, the next step was to categorise the main content described in the individual publications and assign them to the corresponding topic areas within the fields of action in accordance with the underlying scientific framework concept [11,12]. For the field of action 'participation and activities', for example, nine papers discussed 'Physical activities in the context of contact and movement restrictions' and the results of the papers (or the line of argument in discussion papers) all referred to a reduction in physical activity levels following the implementation of social distancing measures. The tabulated summary of the results provides the publications sorted by content category. Likewise, the total number of publications and the proportion of empirical publications are shown by content category, health domain and field of action (Table 1).
were identified within the four separate archives. The authors then transferred hits from the four archives into a single literature database in EndNote and removed duplicates using an automatic procedure. In this literature database, separate searches were carried out for the three fields of action (personal factors, activities/social participation and environmental factors) (Annex Table 3). All citations identified in this way were screened independently by two persons per field: first, the title and abstract were checked, followed by the full text of the remaining relevant hits. Disagreements on whether to include a publication were resolved through discussion or by involving other members of the review team. For this two-stage review, the following exclusion criteria had been defined in advance: (1) unrelated to SARS-CoV-2 or COVID-19, (2) no focus on older people, (3) not published in English or German, (4) unrelated to one of the three fields of action mentioned above, (5) study protocol and (6) drug study.

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The narrative synthesis revealed different topics for the different fields of action, which are listed in Table 1 together with the associated literature. The aim of this scoping review was not providing a detailed analysis of the results.
For physical health, some papers described specific subgroups at particularly high risk of suffering a severe or fatal COVID-19 and highlighted that biological rather than chronological age should be used to assess a person's risk of suf-Statements retrieved from selected German organisa-tions were listed separately (Table 2) with title, reference and responsible organisation; the central topic was described using key words.

Results
Search result By 16 June 2020, a total of 50,108 publications on SARS-CoV-2 infections or COVID-19 had been archived in four separate literature databases at the RKI ( Figure 1). Of these, 47,879 publications were excluded via search query in End-Note as they were not focused on older people. Of the remaining 2,229 publications, 379 duplicates were excluded using an automated procedure. The remaining 1,850 publications formed the basis of the systematic research. The initial search for the fields of action in the literature database using EndNote resulted in a total of 1,068 hits (for all fields of action). The first review (title and abstract) led to the exclusion of 852 publications; the full texts of 216 publications were checked for inclusion.
A total of 149 publications were included for this paper. Of these, 95 were discussion papers  of old age could amplify this. On the other hand, a majority of older people reported good mental health, especially compared to younger adults, in the early stages of the COVID-19 pandemic. However, those older people who suffer more pronounced feelings of loneliness reported more symptoms of anxiety and depression; this was also the case for those with chronic conditions. In the 'physical functioning' domain, it is assumed that physical inactivity due to frequent sitting or lying down as well as loneliness will lead to a deterioration in physical functioning. Frailty is considered a risk factor for more severe and even fatal outcomes of a SARS-CoV-2 infection.
Loneliness, isolation, as well as less support and activation are expected to lead to a deterioration in 'cognitive functioning', especially in dementia sufferers, hospitalised patients and those who become infected with SARS-CoV-2. People suffering cognitive impairments often find it difficult to understand and implement the recommended hygiene measures, putting them at an increased risk of contracting SARS-CoV-2 (especially nursing home residents). Based on the available study data, it cannot be determined to what extent dementia increases the COVID-19 mortality risk.
For the 'health behaviour' domain, there are discussions about how social distancing reduces physical activity, promoting the loss of muscle and endurance and the increase of frailty. With regard to nutrition, older people were described as having difficulty obtaining sufficient healthy food. With regard to alcohol consumption, there is concern that the pandemic could lead to an increase in abuse. However, compared to younger people, older people were less likely to have increased their alcohol consumption during fering severe illness as a result of contracting COVID-19. Reviews discussed the genetic, hormonal and immunological factors potentially contributing to the higher risks faced by older people following an infection with SARS-CoV-2. Publications emphasized the need for further research to better understand age-specific changes to the immune system, also regarding the effectiveness of vaccinating older people against COVID-19. Case studies show that older persons may develop atypical symptoms of COVID-19 (i.e. other symptoms may be present). Reduced levels of physical activity, social isolation and loneliness, as well as changes to overall medical care brought about by the COVID-19 pandemic are expected to lead to a deterioration in the physical health of older people. This risk is believed to be particularly great for older people suffering from cancers, Parkinson's disease, dementia, cardiovascular diseases or osteoporosis. The oral health of older people could also deteriorate. A modelling study concluded that continued physical inactivity in otherwise active, prediabetic older people could lead to an increased incidence of diabetes. An empirical study on emergency neurological care to older people during the COVID-19 pandemic indicated worsened prognoses due to older people delaying seeking medical care.
For the 'mental health' domain, some publications expressed the fear that pandemic-related loneliness and social isolation could have serious effects. An increase in the incidence of various psychological disorders and symptoms is expected, especially in patients with pre-existing mental illnesses or dementia, and those living in nursing homes or who are admitted to hospital. Limited access to the health care system as well as intensive media coverage of the pandemic that, at times, features negative images Social distancing measures likely increase the risk of social isolation, loneliness and physical inactivity among older people, with negative consequences for health and functioning.

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Rapid Review found no evidence that video calls with older people can reduce social isolation, loneliness or symptoms of depression, but the number of studies and the reliability of the evidence were low.
Generally, the pandemic was described as a challenge for older people. Some publications dealt with the blanket classification of older people as a risk group and described their increased stigmatisation and even discrimination as possible consequences. In addition to social isolation, other challenges of the pandemic included financial losses, temporary loss of support and increased social inequality. Individual publications also described opportunities, such as the increased use and improved handling of technology, the strengthening of family networks or increased social awareness of the concerns of the elderly.
The publications considered the settings in which older people live, receive care and how they have been altered by the pandemic. Several empirical contributions analysed infection outbreaks in nursing homes and assisted living settings. Measures of infection control in health care facilities were discussed and suggestions made for coping with social isolation, boredom, reduced contact and quarantine measures. While publications outlined that, as a group, older people have a greater need for protection and support, it the pandemic. An ecological study found a negative correlation at the regional level between COVID-19 morbidity rates and flu vaccination take-up among older people in the previous year. Therefore, low COVID-19 rates were found in places where many people had received a flu vaccination and vice versa. It was also found that older people with low education levels were less likely to follow infection prevention measures than those with a higher education; likewise, men were less likely than women to follow these measures.

Field of action 'Participation and activity'
A total of 26 publications were assigned to the field of action 'participation and activity'.  [116,127,128,152,162].
These studies were focused on the health consequences of containment measures related to the COVID-19 pandemic, specifically social distancing and movement restrictions, for older people. The majority of the papers in this field highlighted a potentially increased risk of social isolation and loneliness for older people -both in nursing homes as well as those living in their own homes -as a result of social distancing measures. Against this backdrop, some papers discussed the role of different professional groups (for example, social workers and health professionals) and public health care, as well as the potential benefits of information technologies. In order to avoid the social isolation of older people, two studies analysed programmes providing telephone contact. The results showed a high level of satisfaction with the service. In contrast, a Cochrane 9 FOCUS (1) infection protection for residents and carers in nursing homes; (2) the equipment provided to nursing homes (e.g. with protective equipment, IT infrastructure); (3) visiting bans and restrictions; (4) the situation facing family caregivers in the home; and (5) the public perception of older people in the context of the COVID-19 pandemic. Table 2 provides an overview of these hits.
The contributions on visiting restrictions addressed the changes that took place during the course of the relaxation of social distancing measures, which started later for nursing home residents compared to other groups. In the context of visiting bans, older people's risk of social isolation and the potential negative consequences were highlighted. Many contributions criticised the vastly different rules that were applied depending on the federal state and the differences regarding the relaxation of restrictions in nursing homes. The situation for family caregivers was also addressed, for example the burdens caused by a lack of care services such as day care facilities, the difficulties for family caregivers who work and the unique burdens placed on relatives caring for people with dementia. Other topics include the demand for a differentiated picture of older people, for example with regard to the risks of SARS-CoV-2 infection, and the avoidance of ageism. remains important to prevent social isolation and ensure the provision of health care services and social support in nursing homes and home care settings. This would require models for cross-sectoral care and the follow-up care of elderly COVID-19 patients. Some publications analysed the challenges health care systems were facing due to the pandemic regarding specific conditions such as hip fractures.
Health care professionals face major challenges in terms of occupational health and safety and workload, especially when caring for people with mental illness or cognitive impairment. Issues related to limited health care resources (including triage and prioritisation), but also palliative care, stereotyping and ageism are also addressed. Issues of social care and security as well as the impact of laws and regulations on older people are also discussed.
Contributions by organisations concerning the pandemic and older people in Germany Until 29 June 2020, contributions related to the pandemic and older people were identified on the websites of 13 of the 14 organisations selected. Of the 57 contributions identified, 47 contributions from a total of ten organisations were included in this review . They include statements, comments and recommendations related to

Number of empirical studies [source]
Approaches to explain the high risk older people face when infected with SARS-CoV-2; role played by genetic, hormonal and immunological factors, as well as pre-existing conditions [26,86,90,148,154] 52 [148,15] Scores to map biological age as a relevant COVID-19 mortality risk factor seem more appropriate than chronological age or sex [ Health issues due to non-use of health care (e.g. follow-up appointments, emergency care) [125,132]

Number of empirical studies [source]
Multifactorial interventions to strengthen the social and health system with the aim of ensuring well-being, prevention and access to health care [   Social hardship of older people in the wake of the COVID-19 pandemic: recommendation for the establishment, support and promotion of local emergency initiatives [199] 07.04.2020 Comprehensive establishment of local emergency aid programmes by municipalities Joint statement by the sections for Geriatric Medicine (II), Social and Behavioural Gerontology (III), Social Gerontology and Assistance for the Elderly (IV) of the German Society of Gerontology and Geriatrics (DGGG e.V.): enabling participation and a social life for older people despite the coronavirus pandemic [198] 24.04.2020 Promoting the self-determination, participation and social inclusion of older people Joint statement by the Social and Behavioural Gerontology (III) and Social Gerontology and Assistance for the Elderly (IV) Sections of the DGGG: participation and care for people with care needs during the coronavirus crisis and beyond [195] 10.05.2020 Participation and care for people with recognised care needs in the context of COVID-19 German Centre of Gerontology (DZA) Old people are different, including in the coronavirus crisis [209] 06.04.2020 Providing a differentiated image of age, using non-age discriminating language Age discrimination and images of age in the coronavirus crisis [208] 07.04.2020 Promoting the physical activity of older people Older people and their use of the internet. Implications for the coronavirus crisis [194] 08.04.2020 Minimising the negative effects of social distancing measures for older people Risks of bans on social contact, social support and voluntary work by and for older people [196] 08.04.2020 Improving the digital involvement of older people COVID-19 pandemic: there is no need to move that fast! No experiments with the elderly and chronically ill population without scientific monitoring [192] 27.03.2020 Systematic documentation and care research in the context of social isolation and visit bans Coronavirus in German nursing homes -an evidence-free drama in three acts [193] 28.04.2020 Clinical-epidemiological database on COVID-19 through systematic testing in nursing homes, establishment of a registry Kuratorium Deutsche Altershilfe e.V. (KDA) The COVID-19 pandemic and the situation of older people in Germany. A statement by the Kuratorium Deutsche Altershilfe (KDA) [200] 07.04.2020 Maintain and enable protection, participation and self-determination of older people and people in need of care Social policy perils and missteps during the coronavirus pandemic.
On the affirmative reception of coronavirus in the culture, spirit and soul of 'Policies for the Elderly' [205] 14.05.2020 Ensure self-determination and participation for older people despite COVID-19 social distancing measures

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Journal of Health Monitoring 2021 6(S4) Older people at the beginning of the COVID-19 pandemic: A scoping review Journal of Health Monitoring 19 FOCUS public health framework of the WHO Action Plan on Ageing and Health, the effects of the COVID-19 pandemic on the three fields of action -personal factors, participation/ activities and environmental factors -were considered [11,12,14].
Only a very small proportion of the extremely high number of publications found for the first six months of the COVID-19 pandemic related specifically to older people's health. The publication hits reveal serious impacts of the COVID-19 pandemic on the health and well-being of older

Discussion
This scoping review aimed to provide an overview of international and German publications on the direct and indirect effects of the COVID-19 pandemic on the health of older people during the first six months of 2020. The main aim of this evaluation was to identify gaps in the evidence concerning the initial phases of the COVID-19 pandemic and, thus, areas requiring further research. Based on a biopsychosocial understanding of health and guided by the   ing only the initial months of the pandemic, it seems plausible that empirical data are predominantly available from countries that were heavily affected early on in the pandemic, such as China [120, 137-139, 147, 153, 154, 163, 164], Italy [121,131,141,146,148] and Spain [128,129,140,150]. This is especially true for empirical studies analysing nursing homes. Only two out of the 50 empirical studies came from Germany, and both analysed medical care. A point to take into account is that continuous data collection, which is common in other countries, for example in US nursing homes with the Resident Assessment Instrument (RAI), does not take place in Germany. During the pandemic, it was either not possible to collect data in German nursing homes or only possible under difficult conditions [192]. Mandatory documentation requirements were suspended in nursing homes in Germany. In addition, visits and monitoring by the Health Insurance Medical Service (MDK) and internal supervision were drastically reduced. This also applied to visits by physicians. There was thus a lack of social control and information on the quality of care during the pandemic is limited [193]. The same applies to the frequency with which patients were sedated, measures that deprive patients of their freedom were applied, or challenging behaviour in dementia patients occurred. As of the reporting date, there were no empirical data available on the situation in home care from the perspective of those affected, care staff or family caregivers. Such studies are, however, now also available for Germany. An overview of the available evidence is being compiled by the Competence Network Public Health COVID-19. Empirical data on physical health that were identified in the research period are largely limited to the observation of the high risk for a people in all three fields of action and the associated health domains. However, in the initial stages of the COVID-19 pandemic, discussion paper (e.g. statements, position papers) predominated overall, while literature reviews (4/149) and empirical studies (50/149) accounted for only a third of hits. The distribution of empirical studies among the fields of action was skewed, each accounting for just under 20% in the 'environmental factors' and 'participation/activities' fields of action compared to 49% in the 'personal factors' field of action.
Many of the empirical studies were based on cross-sectional online surveys with small convenience samples without any claim to representativeness [e.g. 117,119,140,149,158,159], case series [e.g. 132,133,138,150,154,163,164] or individual case studies [e.g. 151,161]. These studies have only limited validity since other sampling strategies are needed for older and very old people with health impairments, for example, nursing home residents [212][213][214]. In addition, there is an urgent need for representative population-based studies of older people living at home in different living contexts (e.g. people living alone in private households with different support and care needs, people with different levels of care dependency, family caregivers) in order to assess the consequences of the pandemic for older people. Here, the evaluations of epidemiological data in Germany collected at the RKI during the course of the pandemic (e.g. GEDA 2019/2020-EHIS, COSMO60+, RKI-Corona-Monitoring, MonAge/Health 65+) can contribute to describing the well-being and health status of older people before and during the pandemic [e.g. 215,216].
Considering the limited time period that was covered by the search ( consequences would include a deterioration in the physical and mental health, as well as the physical and cognitive functions, of older people in nursing homes and private households. Equally unclear is how cause-specific excess mortality will develop and what changes in mortality will occur by place of death. Regarding the vaccination against COVID-19, more research is needed to determine the effectiveness of the various available vaccines, especially in frail and very old people. A central question, which is also increasingly being discussed in international publications [e.g. 219], is how to encourage empirical research on the above-mentioned questions, in particular research requiring personal contact. There will also be a need to clarify the options for analysing the consequences of COVID-19 based on the data provided by official statistics, routine data and epidemiological studies. To meet these challenges, ideally, a publicly accessible online repository (i.e. a scientific document server) for the systematic compilation of results produced by empirical studies concerning older people will become available, such as the one set up for long-term care (Example: LTC-COVID).
Numerous publications highlighted the fact that the COVID-19 pandemic had made social tendencies towards age discrimination visible, and this issue was addressed across fields of action and health domains. Blanket risk assessments and medical triage of COVID-19 patients on the basis of chronological age were mentioned, as was the indiscriminate application of measures to restrict contact and mobility. Some contributions also warned against paternalistic attitudes indicating expectations on how older people should behave (e.g. the demand for self-isolation), severe COVID-19 for particularly vulnerable groups of older people, including older people in nursing homes and frail older people who have undergone emergency hospitalisation following a hip fracture. In general, the situations faced by older people in different countries are certainly similar. However, due to the differences in health care systems between countries, not all findings, especially regarding limited health care during the COVID-19 pandemic, are directly applicable to the situation in Germany.
Overall, men seem to run a higher risk than women of suffering a severe COVID-19. Very few empirical studies on the possible indirect effects of the pandemic on the physical health of older people were available during the research period. The results indicate that fears of negative health consequences due to reduced physical activity resulting from social distancing measures, but also due to a delayed access to medical care, could prove true. Initial empirical studies on the impacts of the pandemic on older people's mental health appear not to confirm the blanket expectation of negative consequences [217,218]. However, during the initial phases of the COVID-19 pandemic, no data on the potential longer-term consequences were yet available.
During the research period, no empirical data were available on the provision of medical care to older COVID-19 patients, nor for acute medical care or for medical and nursing follow-up care for older people recovering from COVID-19. Similarly, no empirical data were identified for assessing how the pandemic impacted the quality of outpatient and inpatient medical care for multimorbid or frail older people, or for developing quality standards. The extent of the short-and medium-term health consequences of the pandemic for older people also remains unclear. Such The COVID-19 pandemic highlights the threat of age discrimination and the need to raise societal awareness of the fact that older people form a heterogeneous group.
Journal of Health Monitoring 2021 6(S4) Older people at the beginning of the COVID-19 pandemic: A scoping review Journal of Health Monitoring 22 FOCUS are available to judge the quality of discussion papers, which make up the majority of the included papers.

Conclusion
The results of this systematic literature review up to June 2020 show that a wide range of direct and indirect effects of the COVID-19 pandemic on the health and well-being of older people can already be expected even during the initial stages of the pandemic. There is an urgent need for empirical research, especially implementation and intervention research, that addresses both infection prevention and control as well as the impact of containment measures on older people in a wide range of life situations throughout the COVID-19 pandemic. Individual (intrinsic) health, functional and social resources and external contextual factors, such as living circumstances, medical and nursing care and social support services, must be taken into account. During the COVID-19 pandemic, it has become clear that continuous and systematic health reporting for the population aged 65 and older is needed; it must also be able to take into account the heterogeneity of this age group. For this purpose, a basis of data needs to be established that can be used in a low-threshold manner and enable timely analyses. The COVID-19 pandemic has shown the danger of a generalising and partly discriminatory approach regarding age. The reality of demographic change requires a differentiated and future-oriented approach to this topic in all areas of society.
potentially limiting their freedom of choice [46,54]. There were calls for a social discourse that recognises the heterogeneity of old people as a group and adapts medical, nursing and social care structures to the largely diverse needs of older people and particularly vulnerable groups (e.g. people in need of care, those who are socially isolated or physically and cognitively impaired). Including new technologies and digital media in a process of adaptation that leads to the creation of appropriate infrastructures and services at the individual and municipal level was seen as a challenge, but also as an opportunity.
This scoping review has its strengths and limitations. The search was conducted for the period from 1 December 2019 to 16 June 2020 in literature archives prepared by the RKI and thus refers exclusively to the initial phase of the COVID-19 pandemic. The systematic search relied on the two most important medical and health science databases, PubMed and Embase, as well as several preprint servers. The search terms were broadly discussed and agreed upon by the authors and included keywords as well as free text terms. To provide findings that reflect the situation in Germany, national contributions via the websites of relevant organisations were included in addition to the literature search. For our study objective, i.e. to provide a systematic overview of the current discourse on the situation of older people during the initial stages of the COVID-19 pandemic, this search strategy seems suitable, but does not claim to be exhaustive. An important limitation of our analysis is that the quality of the studies included was not assessed. However, the aim of the review was to take account of the topics and issues being discussed and not to assess the study results. Furthermore, no quality assessment tools There is an urgent need of research on the effects of non-pharmaceutical interventions to protect older people.